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� Backwater Prevention Device Rebate Program <br /> fv �n �euate Application �of�m <br /> Property G��;ner IJame: -- –__ �� -----�I <br /> i Inslallaiion Addie;s 1=/ I _ _ _ v� � <br /> � I <br /> ' ���y �1le��-�4 ����P _ _�_z�� 9�SZ� � <br /> � <br /> ; <br /> �Liailing Adtlress (d diBe�ent). — -- <br /> �ity. State __7_ic: I <br /> cm�:��� ��►;�a��,_�P�,o:�z �9� - - - ��, <br /> � Total Cost to Install Device (lrorn confractor invoice): S 2`� 9 � , 5(� _ _ I <br /> I _--- --._. _.J <br /> `------ -------- ---. --. <br /> Please verify the following: <br /> �_ I am the owner of the property v:here lhe backwater preven;ion device v:as install2d <br /> ���vorked �vith the contractor eo determine the Iocation for the backwater pre��ention ee�nce and I <br /> understand that the decision regarding the location of the device�vas mine. ` <br /> f�l IJ�y contraclor instructed me how to access, inspect, and maintain the device. i <br /> ,�� <br /> �I understand that I am responslble (or rr,alnlaining "•e hackwaler prevenlion device and keepiny I <br /> rt in good working order, uniess it is installed in Ihe cily riyhl�of-�vay. <br /> �It I sell my property, I will make potentia! huyers 2e+are of ihe backwater prevention device and <br /> ihe need to inspect and mainiain it on a regular basis. <br /> ;_ I am endosing all of the necessary papeiv�ork(use ihe yeilow Rebate SubmiUal Chcc�list). <br /> Sclecl fram thc following: <br /> i ] The contrar,tor �denti(ied downspou;s or other dra�nage Ilines Ihat were conneded to my se�ver <br /> line (belween my house and Ihe inslalled device) and removed, or rerouted lhem <br /> , To my knowledge, m�� property has no downspoufs or o�'ier drain2ge r.onnected to my se�ver Icie <br /> ( etv;een my hcuse and the inslalled device). <br /> [� �I.erP are downspouts or other drainage lines connect�d to my sewer line (between my house <br /> a���l Ihe ins;r�iled device). I understand thal leaving these connections creates a risk of fleoding <br /> ar�d I acci�p' Ihal r.sk. <br /> Signature __ __ Dafc (��-�,,� <br />